Basic Information
| Provider Information | |||||||||
| NPI: | 1053917849 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RIDGELAND MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 587 HIGHWAY 51 STE T | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391572567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017907711 | ||||||||
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| Practice Location | |||||||||
| Address1: | 587 HIGHWAY 51 STE T | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391572567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017907711 | ||||||||
| FaxNumber: | 6017907712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2020 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | JODY | ||||||||
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| AuthorizedOfficialTitleorPosition: | NURSE PRACTITIONER | ||||||||
| AuthorizedOfficialTelephone: | 6017907711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | FNP | ||||||||
| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.